Failure to Timely Report Abuse Allegation and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse and injuries of unknown origin to the state survey agency within the required two-hour timeframe, as required by facility policy and regulatory expectations. The facility’s Abuse, Neglect and Exploitation policy states that all alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. Despite this, the facility did not meet the two-hour reporting requirement for two separate incidents involving two residents. In the first incident, a resident with a history of stroke, traumatic brain injury, major depressive disorder, and anxiety disorder, and documented short- and long-term memory problems, allegedly indicated possible sexual abuse. The non-verbal resident pointed to their genital area and then to a certified medication aide. The incident occurred at approximately 7:00 p.m., and staff including a receptionist, an LPN, and a unit manager became involved in assessing the allegation. The administrator, who served as the abuse coordinator, participated by phone during the resident interview. However, the state survey agency did not receive the facility’s initial report until after 10:18 p.m., more than three hours after the incident occurred and beyond the two-hour reporting requirement. Staff interviews confirmed their understanding that allegations of abuse, including sexual abuse, must be reported to the state within two hours of the facility becoming aware of the allegation. In the second incident, a resident with type 2 diabetes mellitus, chronic kidney disease, dementia, blindness, and significant ADL self-care deficits was found to have a subdural hematoma while at the hospital. The resident’s family member reported to the facility that the hospital physician indicated the subdural hematoma could have been caused by a fall or a strike to the head, constituting an injury of unknown origin. The family reported this information to the facility on one day, but the administrator did not report the allegation to the state survey agency until the following day. The administrator acknowledged that the allegation should have been reported within two hours of the facility being made aware of it, and both the DON and administrator stated their expectation that injuries of unknown origin be reported to the state within two hours, which did not occur in this case.
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